MSK Flashcards
S/S of Patellofemoral pain syndrome?
Patellofemoral pain syndrome, also known as runner’s knee, refers to anterior knee pain due to poor tracking of the patella over the distal femur. Symptoms typically include anterior knee pain that worsens while going up or down stairs and hills, or by prolonged sitting with knees flexed. The J-sign is named for the course of the patella tracking in the joint with contraction of the quadriceps. Patellofemoral syndrome is associated with weakness of the vastus medialis as compared to the vastus lateralis and leads to abnormal lateral tracking of the patella. Radiographs are usually normal. Initial treatment includes rest, ice, and analgesia followed by training with special attention to strengthening the vastus medialis.
What is a “trigger finger”? Treatment?
The most likely diagnosis in this patient is “trigger finger,” which is a type of stenosing tenosynovitis. Patients initially describe painless snapping, catching, or locking of one or more fingers during flexion of the affected digit. This often progresses to painful episodes in which the patient has difficulty spontaneously extending the affected digits. The differential diagnosis includes Dupuytren contracture, diabetic cheiroarthropathy, metacarpopharyngeal (MCP) joint sprain, infection of the tendon sheath, calcific peritendinitis or periarthritis, or noninfectious tenosynovitis. The initial management of trigger finger is conservative management with stretching and splinting. The addition of NSAIDs or acetaminophen would also be appropriate for initial management. In patient’s with chronic kidney disease, such as this patient, prolonged NSAIDs may not be appropriate.
Guyon Canal syndrome gives what symptoms?
Guyon canal syndrome occurs when there is entrapment of the ulnar nerve as it passes through the wrist. Anatomically, the ulnar nerve is entrapped as it passes through the tunnel formed by the pisiform and hamate bones and the pisohamate ligament at the level of the wrist. This can lead to atrophy of the hypothenar eminence and impairs both adduction and abduction all fingers. Sensory findings are often absent in ulnar nerve entrapment at Guyon canal, as the sensory innervation tends to branch out from the ulnar nerve prior to entering Guyon canal (for example, the dorsal ulnar cutaneous nerve branches off about 5 cm proximal to the wrist); however, due to anatomic variance, sometimes paresthesias to the palmar surface of digits 4 and 5 may be present.
What is Osteomalacia?
Osteomalacia is a condition caused by defective bone mineralization primarily due to vitamin D deficiency. Causes include inadequate sun exposure, poor dietary intake (common in vegans), chronic kidney disease, and problems with malabsorption (such as post gastric bypass or in celiac disease). Osteomalacia can also be caused by hypophosphatemia (such as in Fanconi syndrome) or from certain medications (such as bisphosphonates).
During bone turnover, the decreased mineralization causes focal accumulation of newly formed osteoid. Radiographically this manifests as radiolucent lines with sclerotic borders commonly known as “pseudofractures”; the combination of multiple symmetric and bilateral pseudofractures is known as Milkman syndrome.
What is subacromial Bursitis?
The most likely diagnosis in this patient is subacromial bursitis, given the patient’s history and the clinical examination findings of worsening pain with overhead activity, pain relief with rest, warmth over the affected shoulder, unremarkable rotator-cuff testing, and negative x-ray. Subacromial bursitis is a common cause of shoulder pain. The subacromial space in the shoulder is bordered superiorly by the acromion, the coracoid, the coracoacromial ligament, and the proximal deltoid and inferiorly by the supraspinatus. Inflammation of this bursa, most commonly from overhead repetitive movements, often results in chronic shoulder pain.
Bursitis differs from arthritis in that patients with arthritis have worsening pain with inactivity, symptoms gradually worsen over months to years, and x-ray imaging often shows findings of degenerative joint disease. Subacromial bursitis is initially treated with conservative management, including rest, activity limitation, physical therapy, and nonsteroidal anti-inflammatory drugs (NSAIDs). When these initial treatment modalities fail to improve the pain, patients can be offered a corticosteroid injection into the subacromial space. Operative treatment is reserved for cases that are refractory to conservative management.
What injury is often associated with a distal radial shaft fracture?
The exhibit in the stem demonstrates a distal radial shaft fracture. The most common other injury associated with this type of fracture pattern is the distal radioulnar joint.
How do we treat Fragility fractures? Osteoporosis screening and treatment?
This elderly woman, who is presenting for follow-up with a femoral neck fracture sustained during a ground-level fall, meets the criteria for a fragility fracture. Fragility fractures without other underlying causes (for example primary bone or metastatic tumor) are diagnostic of osteoporosis. The most appropriate next step after the diagnosis of osteoporosis has been made is to initiate secondary prevention with a bisphosphonate, such as alendronate.
Osteoporosis is a common metabolic bone disease characterized by decreased bone strength and abnormal bone density. It is more common in inactive, postmenopausal, Caucasian women. Patients with osteoporosis may present with a hip fracture, wrist fracture, or vertebral compression fracture. This patient has multiple risk factors for osteoporosis, including a thin build and a longstanding history of tobacco use. All patients greater than 65 years of age, as well as patients between 40 and 60 years of age with at least one risk factor for fractures after menopause, should be screened with a dual-energy x-ray absorptiometry (DEXA) scan of the spine and hip. This patient does not need screening because osteoporosis can be diagnosed on DEXA or in the presence of a fragility fracture, as in this patient’s case. Secondary causes of osteoporosis include smoking, alcoholism, renal failure, hyperthyroidism, multiple myeloma, hyperparathyroidism, vitamin D deficiency, hypercortisolism, and heparin and chronic steroid use. These etiologies can be considered when the patient has risk factors and laboratory findings consistent with these disease states. Management involves the use of bisphosphonates, teriparatide, selective estrogen receptor modulators (SERM), and intranasal calcitonin.
What is torn during a Lateral epicondylitis?
This patient is suffering from lateral epicondylitis, which is also known as “tennis elbow.” Lateral epicondylitis is an overuse injury of the forearm extensors and supinators and is common among amateur tennis players using an improper technique when hitting groundstrokes from the backhand side. Anatomically, this condition occurs as a result of microscopic tearing within the origin of the extensor carpi radialis brevis tendons and presents with pain at the lateral aspect of the elbow. Typical treatment is rest, ice, nonsteroidal anti-inflammatory drugs (NSAIDs), and a forearm strap over the proximal extensor carpi radialis tendon. Osteopathic manipulative treatment (OMT) includes myofascial release within the forearm and counterstrain to the affected muscles.
ACL tears affect who? Most sensitive test? Common associated findings?
This patient is most likely presenting with an anterior cruciate ligament (ACL) tear. The ACL is the most commonly injured knee ligament. Most ACL tears occur from non-contact athletic injuries. Two common sports where ACL tears frequently occur are football and gymnastics. ACL tears are usually contact-related in football athletes, while ACL tears are non-contact related in gymnasts. Football players experience the highest number of ACL tears overall due to the number of players. However, female gymnasts experience a greater number of tears per athletic exposure. Overall, women experience ACL tears at significantly higher rates than men. There are currently 5 proposed explanations to account for the gender disparity involving ACL tears as follows: (1) quadriceps-dominant deceleration; (2) increased valgus knee angulation; (3) effects of estrogen; (4) discrepancies in quadriceps angle; and (5) decreased intercondylar notch width.
The most sensitive test for an acute ACL tear is the Lachman test. The Lachman test is performed by placing the knee in approximately 30 degrees of flexion, with one hand stabilizing the distal femur. The other hand pulls the proximal tibia anteriorly while attempting to produce an anterior translation of the tibia on the femur. An intact ACL limits anterior translation and will provide a distinct endpoint. Comparison of the uninjured knee allows for a better “feel” and understanding of this endpoint. The Lachman test is the most useful test in an acute ACL rupture, as it has a sensitivity of 81.8% and a specificity of 96.8%.
ACL tears typically present with immediate swelling. There is often the feeling of a pop followed by instability. The location of pain may vary, but it is often felt laterally. An x-ray may demonstrate an avulsion fracture of the anterolateral tibial plateau. This is called a Segond fracture and suggests the presence of an associated ACL tear, as in this patient.
What findings is seen in Paget’s disease?
A mosaic lamellar bone pattern is pathognomonic for Paget disease. This disease is commonly seen in patients older than 40 who complain of bone and joint pain with hearing loss due to enlargement of the temporal bone causing nerve entrapment. Laboratory abnormalities would reveal high levels of alkaline phosphatase with normal calcium and phosphate. Such patients are at increased risk for osteosarcoma.
What is Osteomalacia?
Osteomalacia can be asymptomatic, but commonly presents with nonspecific bone pain, especially in the legs and pelvis, and is associated with insufficiency fractures which are sometimes called Looser zones, cortical infractions, Milkman lines, or pseudofractures.
